| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | There is no record of a fire drill being completed on 8/1/2025 when individual #1 moved into the home. The only fire drill on record was completed 8/12/2025. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | A fire safety tracking spreadsheet was created effective 09/30/2025, which will include dates for fire drills and individual fire safety training dates. All drill dates and training dates will be added prior to 11/01/2025. A special notation is made is a drill is being conducted for the purpose of a new admission. |
11/01/2025
| Implemented |
| 6400.113(a) | There was no record of fire safety training completed when individual #1 was admitted to the home on 8/1/25. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The individual is scheduled for fire safety training on 10/09/2025. A fire safety tracking spreadsheet was created effective 09/30/2025, which includes dates for fire drills and individual fire safety training dates. All dates will be updated on the spreadsheet prior to 11/01/2025. |
11/01/2025
| Implemented |
| 6400.212(a) | A social Security Income letter for another individual supported by the agency was found in individual #1's record. | A separate record shall be kept for each individual.
| Effective 09/09/2025, the social security income letter for another individual was removed from individual #1's record. |
11/01/2025
| Implemented |
| 6400.34(a) | The individual rights statement that includes the right to lock the bedroom door that individual #1 signed is not dated so it is impossible to determine if it was completed when the individual was admitted to the home on 8/1/25 as per regulation. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Effective, 09/11/2025, AOA re-informed and explained individual rights and the process to report a rights violation to individual #1 and obtained a newly signed and dated statement. |
10/06/2025
| Implemented |
| 6400.166(a)(11) | The MAR for individual #1 does not indicate the diagnosis or purpose for medication for PRN Trazodone 50 mg 0.5 tablet | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Effective 09/09/2025, the MAR was updated to include the diagnosis or purpose of the medication. |
11/01/2025
| Implemented |
| 6400.166(b) | During the medication review for Individual #1, the 9/9/2025, 8am dose of Risperidone 2mg was noted as "missed pass" on electronic mar. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Program Director confirmed that the risperidone 2 mg 8 am dose was administered on 9/9/2025 via count of the medication on hand. The Program Director corrected the documentation error on the eMAR effective 09/09/2025. |
10/06/2025
| Implemented |